"Melanoma: Watch Your Back" 
Article authored by
Anastasia Petro, MD, Jennifer Schwartz, MD

These days it's not only the suspicious stranger lurking behind your back that you have to watch. In the United States, you are more likely to run into trouble from a melanoma on your back, the most common location of this potentially deadly skin cancer.

Each year over a million people in the United States alone will be diagnosed with skin cancer. Of these, approximately 80,000 will be afflicted with melanoma. The incidence or the number of new cases of melanoma per year continues to rise. One in seventy-one persons born in the year 2001 will develop melanoma over their lifetime. Although it is not the most common skin cancer, melanoma is the most aggressive and has the ability to spread to other parts of the body.

Melanoma is a malignant tumor that is made up of abnormal melanocytes. Normal melanocytes, which reside in everybody's skin, are cells that produce a brown pigment called melanin. Melanin is the major determinant of a person's skin color and also serves as the body's own natural sunscreen. A melanoma develops when certain melanocytes are no longer able to control their own growth and continue to multiply at a fast rate. This phenomenon occurs when melanocytes undergo significant damage. Too much exposure to sunlight, especially enough to cause blistering or peeling sunburns during childhood, can result in enough cellular injury to cause a melanoma as well as other skin cancers. In addition, there are other factors that make a person more susceptible to developing a melanoma. These include:
Blond or red hair, blue eyes, or fair skin
More than 100 normal moles or many unusual moles
Previous history of a melanoma
Blood relative(s) with a melanoma

You can't change the way you look or your relatives. However, you can reduce your risk of melanoma by wearing plenty of sunscreen that protects against both ultraviolet A and B rays, avoiding sun exposure between the hours of 10 AM to 4 PM when the sun is brightest, seeking shade, and covering yourself up with clothing.
In general, early detection of any cancer including melanoma increases the likelihood of a complete cure. The most likely person to detect an early skin cancer is you! We do not expect you to be able to diagnosis skin cancer but simply being aware of changes occurring on your skin may save your life. There are three main points that you need to know in order to properly perform a self-skin-examination:

Point #1: Melanoma can occur anywhere on the body from head to toe, although it is most common on sun-exposed skin. Therefore, you should examine your skin everywhere, including the palms of your hands and soles of your feet. Mirrors may be used to inspect areas that you are unable to directly visualize.

Point #2: "Know your ABCD's." These are different than the ones we all learned in Kindergarten. The "ABCD's" are comprised of four descriptive features, which many melanomas have. Keep in mind that the "ABCD's" are not perfect criteria and are meant to be used as a general guide for you to examine your skin. The bottom line is for you to remember to check your skin. If any spots on your body have a change in size, shape, or color or make you uncomfortable, the best action is to undergo a formal examination by a trained and experienced healthcare professional.

"A" for Asymmetry
Basically one side does not look like the other.

"B" for Border Irregularity
Jagged, irregular borders are more worrisome than smooth borders.

"C" for Color Variation
Different colors in the same lesion can be a sign of an abnormal lesion.

"D" for Diameter > 6mm
Lesions larger than a head of a pencil eraser (about 6mm) are more concerning for melanoma.


Point #3: Remember that 70% of melanomas develop in normal skin while 30% start in a mole.

If you think that you may have a melanoma, the next step is to see your primary care physician or a dermatologist, a specialist of the skin. If your doctor suspects a skin cancer, he or she may refer you to a dermatologist for further evaluation or may perform a biopsy of the lesion during the office visit. The skin biopsy (the act of taking a sample of skin) is performed to confirm the diagnosis of melanoma. If the biopsy is positive for melanoma, then further treatment will be required. In addition, when diagnosed with a melanoma, a total body skin and lymph node examination should be performed. At the office visit, patients should be asked questions regarding their general health. Depending on the biopsy results and the information obtained by the clinician during this thorough history and physical inspection, additional laboratory tests may be warranted. Also, patients should be encouraged to inform other family members, whose risk of developing a melanoma may be higher, about their diagnosis. These family members often benefit from skin examinations as well.

The first step in treating melanoma will usually involve total removal of the melanoma, if complete removal at the time of biopsy is not possible. For melanoma, prognosis is mainly based on the greatest thickness of the primary tumor into the skin, which is known as the Breslow depth. The Breslow depth will determine the necessary treatment. This includes how much additional skin tissue surrounding the melanoma will need to be removed for the greatest likelihood of a cure. This is referred to as the surgical margin, which typically ranges between 0.5 cm and 2 cm, depending on the thickness of the melanoma. For thin melanomas, this may be the only treatment. However, for thicker melanomas, additional procedures may be recommended.

Certain patients with thicker melanomas may be candidates for sentinel lymph node mapping. Lymph nodes are important because they are the most common sites (after the surrounding skin) to which melanoma spreads. Thicker melanomas, as defined by the Breslow depth, have a higher chance of metastasizing, or spreading, to the lymph nodes. The sentinel lymph node is defined as the first lymph node to which the primary melanoma is most likely to have spread. Mapping the location of the sentinel lymph node involves injection of a special dye and radioactive material at the site of the primary melanoma. If the sentinel lymph node has no evidence of melanoma, then in many patients no further treatment is required. However, if the sentinel lymph node is positive, then removal of all the other lymph nodes in the same area is necessary. Also, these patients may be considered for other non-surgical therapies, such as interferon. Interferon is a substance that boosts a person's immune system, which plays a key role in helping the body fight infections as well as cancer including melanoma.

If melanoma has metastasized, or spread, beyond the lymph nodes, the chance for cure decreases. The treatment for metastatic melanoma may involve immunotherapies, which can include vaccines, and other chemotherapeutic agents. These patients are usually under the care of medical oncologists, specialists who treat cancer non-surgically.

Photographs of Cutaneous Melanomas:

Note asymmetry and
irregular border

Note asymmetry, large size,
irregular border, and color

Note irregular border
and color

Note asymmetry and irregular border

Like many cancers, early diagnosis is an important factor for prognosis and treatment of melanoma. Worrisome spots or those that are changing in size, shape, and/or color as well as lesions that are persistently bleeding or itching should be examined by a trained medical professional skilled at diagnosing skin lesions.

Anastasia Petro, M.D., Resident, Department of Dermatology, University of Michigan
Jennifer Schwartz, M.D., Lecturer, Department of Dermatology, University of Michigan

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